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Dias de Castro E, Pinhal AL, Bragança M, Parente Freixo J, Martinho A. Hereditary angioedema with normal C1-inhibitor: Clinical and genetic characterization of 15 Portuguese unrelated families. Ann Allergy Asthma Immunol 2024; 132:730-736. [PMID: 38342132 DOI: 10.1016/j.anai.2024.01.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Revised: 01/09/2024] [Accepted: 01/26/2024] [Indexed: 02/13/2024]
Abstract
BACKGROUND Hereditary angioedema with normal C1-inhibitor (HAE-nC1-INH) is a rare genetic disease with similar phenotype to HAE-C1-INH but different genetic background. Currently, 6 subtypes are recognized, based on the underlying mutations. Several aspects need further clarification. OBJECTIVE To assess clinical features of patients with genetically characterized HAE-nC1-INH from the North of Portugal. METHODS Retrospective assessment of clinical data from all patients with HAE-nC1-INH followed at a HAE Reference Center. RESULTS A total of 41 patients were identified, 4 with no family history. The FXII mutation Thr328Lys (38 carriers) was the most prevalent. There were 3 new potentially disease-causing variants linked to HAE-nC1-INH identified (c.529+4A>G:FXII; Cys248*:Kininogen-1; and Arg261His:Plasminogen). The HAE-FXII cohort included 82% females and 71.8% symptomatic patients. Penetrance rate was significantly higher in females (81.3% vs 28.6%; P = .012). A hormonal influence was observed in 96.2% of the symptomatic females, although 62.5% remained symptomatic after oral estrogen withdrawal. Trauma and dental procedures were frequent triggers (82.6% and 45.5%, respectively). Main locations were facial (described by 96%), lips (82.1%), and eyelids (64.3%). One patient reported erythema marginatum as prodrome. Plasma-derived C1-INH was effective as short-term prophylaxis in all treated patients, but only in 80% as on-demand treatment. Icatibant was effectively used on demand in 9 patients, but with relapses in 5 (57%). CONCLUSION We described a large Portuguese series of patients with HAE-nC1-INH genetically characterized. Differences with others may contribute to improve current unmet needs and raise awareness of this rare disease. We highlighted the identification of 3 new variants (additional molecular studies are ongoing) and the report of erythema marginatum in HAE-nC1-INH.
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Affiliation(s)
- Eunice Dias de Castro
- Allergy and Clinical Immunology Department, Centro Hospitalar Universitário de S. João EPE, Porto, Portugal; Public Health and Forensic Sciences and Medical Education Department, Faculty of Medicine, University of Porto, Porto, Portugal.
| | - Ana Luísa Pinhal
- Allergy and Clinical Immunology Department, Centro Hospitalar Universitário de S. João EPE, Porto, Portugal
| | - Mariana Bragança
- Allergy and Clinical Immunology Department, Centro Hospitalar Universitário de S. João EPE, Porto, Portugal
| | - João Parente Freixo
- Center for Predictive and Preventive Genetics, Institute for Molecular and Cell Biology, University of Porto, Porto, Portugal; Instituto de Investigação e Inovação em Saúde, University of Porto, Porto, Portugal
| | - António Martinho
- Centro do Sangue e Transplantação de Coimbra, Centro Hospitalar Universitário de Coimbra, Coimbra, Portugal
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Radojicic C, Anderson J. Hereditary angioedema with normal C1 esterase inhibitor: Current paradigms and clinical dilemmas. Allergy Asthma Proc 2024; 45:147-157. [PMID: 38755781 DOI: 10.2500/aap.2024.45.240010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2024]
Abstract
Background: A diagnosis of hereditary angioedema (HAE) with normal C1 esterase inhibitor (HAE-nl-C1-INH) can be challenging and pharmacologic management is not well defined. Objective: The objective was to discuss practical considerations in the clinical management of HAE-nl-C1-INH by using illustrative clinical vignettes to highlight and/or address select challenges. Methods: This was a narrative review. Results: Symptoms of HAE-nl-C1-INH overlap with HAE types I and II; the heterogeneity of presentation and symptom burden are diagnostic challenges. A patient history, with particular attention to whether urticaria or other symptoms of mast cell mediator release are present, is important because such symptoms would strongly suggest a mast cell-mediated pathway. A family history of angioedema is informative but a lack thereof does not rule out diagnosis. Expected laboratory findings would be normal for C4, C1-INH level and function, and Complement 1q; a genetic mutational analysis may be helpful, but current assays do not include all known mutations; most cases are categorized as unknown. To align with guideline-directed treatment approaches, the following stepwise approach is suggested for suspected HAE-nl-C1-INH: (1) thoroughly investigate the possibility of response to histaminergic and/or mast cell-targeting treatments; (2) if patients with normal C4, C1-INH level and/or function fail adequate trials with histamine/mast cell-directed therapy or have a mutation that suggests bradykinin pathway involvement, follow HAE type I and II treatment guidelines. Response to medications approved for HAE types I/II provides compelling support for a high clinical suspicion of HAE-nl-C1-INH. De-labeling an HAE-nl-C1-INH diagnosis may be appropriate if the initial diagnosis was made without adequate evaluation or if new information and/or testing indicates that the patient does not actually have HAE. Conclusion: Key unmet needs in HAE-nl-C1-INH include lack of confirmatory biomarker(s) for diagnosis and lack of prospective controlled clinical studies of pharmacologic products in this patient population.
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Affiliation(s)
- Cristine Radojicic
- From the Division of Pulmonary, Allergy and Critical Care, Department of Medicine, Duke University, Durham, North Carolina
| | - John Anderson
- Division of Pulmonary Allergy, Critical Care in Sleep Medicine, Department of Internal Medicine, University of Alabama, Birmingham, Alabama, and
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Demir S, Eyice‐Karabacak D, Kocatürk E, Ünal D, Toprak İD, Korkmaz P, Aslan AF, İmren IG, Dikicier B, Kahveci N, Öztop N, Kara RÖ, İşsever H, Maurer M, Weller K, Gelincik A. Monitoring recurrent angioedema: Findings from the Turkish angioedema control test validation study. Clin Transl Allergy 2024; 14:e12342. [PMID: 38415974 PMCID: PMC10900914 DOI: 10.1002/clt2.12342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 01/29/2024] [Accepted: 01/31/2024] [Indexed: 02/29/2024] Open
Abstract
BACKGROUND Determination of control level in recurrent angioedema (RAE) is necessary to guide management. Here, we validated a Turkish version of the angioedema control test (AECT) for 4-week (AECT-4wk) and for 3-month (AECT-3mth) and assessed their utility in monitoring RAE. METHOD The recommended structured translation process for patient-reported outcome measures was completed. The final versions were administered to 51 patients with mast cell-mediated angioedema (MMAE) and 38 patients with hereditary angioedema, and the minimal clinically important difference (MCID) was determined. Additionally, anchor surveys comprising angioedema activity score for 28 days (AAS-28 day), visual analog score for angioedema control, Likert scale for the control level from the patient's perspective (LS-AEC), angioedema quality of life, short form-12 (SF-12) and patients' assessment of treatment sufficiency were applied. RESULTS The Turkish AECT versions showed good convergent validity with a substantial correlation with anchor tools and known-group validity. Excellent internal consistency and reproducibility were observed. Equal or more than 10 of 16 points scored with the AECT-4wk and AECT-3mth identified patients with well-controlled disease. The disease activity, control and burden parameters were consistent with the disease control level defined depending on the cut-off point 10 of AECT. Three-point changes in AECT-4wk and -3 mt could detect MCID in disease control in all patients. CONCLUSIONS Turkish AECT versions are valid and reliable tools for assessing and monitoring disease control in patients with RAE. The use of the Turkish versions of the AECT in routine patient care, clinical trials and angioedema research is recommended.
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Affiliation(s)
- Semra Demir
- Division of Immunology and Allergy DiseasesDepartment of Internal MedicineIstanbul Faculty of MedicineIstanbul UniversityIstanbulTurkey
| | - Deniz Eyice‐Karabacak
- Division of Immunology and Allergy DiseasesDepartment of Internal MedicineIstanbul Faculty of MedicineIstanbul UniversityIstanbulTurkey
| | - Emek Kocatürk
- Department of DermatologyKoç University Faculty of MedicineIstanbulTurkey
- Institute of AllergologyCharite‐UniversitatsmedizinCorporate Member of Freie Universitat Berlin and Humboldt‐Universitat zu BerlinBerlinGermany
- Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Immunology and AllergologyBerlinGermany
| | - Derya Ünal
- Division of Immunology and Allergy DiseasesDepartment of Internal MedicineIstanbul Faculty of MedicineIstanbul UniversityIstanbulTurkey
| | - İlkim Deniz Toprak
- Division of Immunology and Allergy DiseasesDepartment of Internal MedicineIstanbul Faculty of MedicineIstanbul UniversityIstanbulTurkey
| | - Pelin Korkmaz
- Division of Immunology and Allergy DiseasesDepartment of Internal MedicineIstanbul Faculty of MedicineIstanbul UniversityIstanbulTurkey
| | - Ayşe Feyza Aslan
- Division of Immunology and Allergy DiseasesDepartment of Internal MedicineIstanbul Faculty of MedicineIstanbul UniversityIstanbulTurkey
| | - Işıl Göğem İmren
- Division of Immunology and Allergy DiseasesDepartment of Internal MedicineIstanbul Faculty of MedicineIstanbul UniversityIstanbulTurkey
| | - Bahar Dikicier
- Faculty of MedicineDepartment of DermatologySakarya UniversitySakaryaTurkey
| | - Nevzat Kahveci
- Division of Immunology and Allergy DiseasesDepartment of Internal MedicineIstanbul Faculty of MedicineIstanbul UniversityIstanbulTurkey
| | - Nida Öztop
- Adult Allergy and Immunology ClinicBaşakşehir Pine and Sakura City HospitalIstanbulTurkey
| | - Rabia Öztaş Kara
- Faculty of MedicineDepartment of DermatologySakarya UniversitySakaryaTurkey
| | - Halim İşsever
- Istanbul Faculty of MedicineDepartment of Public HealthIstanbul UniversityIstanbulTurkey
| | - Marcus Maurer
- Institute of AllergologyCharite‐UniversitatsmedizinCorporate Member of Freie Universitat Berlin and Humboldt‐Universitat zu BerlinBerlinGermany
- Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Immunology and AllergologyBerlinGermany
| | - Karsten Weller
- Institute of AllergologyCharite‐UniversitatsmedizinCorporate Member of Freie Universitat Berlin and Humboldt‐Universitat zu BerlinBerlinGermany
| | - Aslı Gelincik
- Division of Immunology and Allergy DiseasesDepartment of Internal MedicineIstanbul Faculty of MedicineIstanbul UniversityIstanbulTurkey
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Muna ND, Ahmed TA, Madaka SK, Nimer TZ, Hamdan SI, Ghaith SN, Alshaer TJ, Naqib M. Hereditary Angioedema With a Normal Complement Level. Cureus 2024; 16:e52291. [PMID: 38357063 PMCID: PMC10865421 DOI: 10.7759/cureus.52291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2024] [Indexed: 02/16/2024] Open
Abstract
Hereditary angioedema (HAE) is an uncommon autosomal dominant disorder, characterized by episodes of oropharyngeal, gastrointestinal, and subcutaneous tissue swelling, often accompanied by discomfort. HAE is primarily associated with mutations in the SERPING1 gene, resulting in insufficient levels or impaired function of C1 esterase inhibitor (C1-INH), an important regulatory protein of the complement system. While types 1 and 2 HAE are well-established entities caused by quantitative and qualitative defects in C1-INH, respectively, the emergence of type 3 HAE, also known as estrogen-dependent HAE, has expanded our understanding of this complex disorder. In this case, a 2-year-old girl with Down syndrome visited the ER after experiencing lip and tongue swelling following the ingestion of ground pepper. Her laboratory results showed that her complement levels were within normal limits despite clinical symptoms. This situation leads to the specific variant of hereditary angioedema called hereditary angioedema with a normal C1 esterase inhibitor (HAE-NI-C1-INH). Although there are currently no approved treatments, positive responses have been seen to her use of C1-INH concentrate and tranexamic acid to alleviate both immediate and delayed symptoms.
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Affiliation(s)
- Nidal D Muna
- Faculty of Medicine, Al-Quds University, Abu Dis, PSE
| | | | | | - Tareq Z Nimer
- Faculty of Medicine, Al-Quds University, Abu Dis, PSE
| | | | - Sara N Ghaith
- Faculty of Medicine, Al-Quds University, Abu Dis, PSE
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Lumry WR, Bernstein JA, Li HH, Levy DS, Jones DH, Padilla BE, Li-Mcleod J, Tachdjian R. An expert panel's review on patients with hereditary angioedema switching from attenuated androgens to oral prophylactic therapy. Allergy Asthma Proc 2024; 45:44-49. [PMID: 38151740 DOI: 10.2500/aap.2024.45.230080] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2023]
Abstract
Background: Hereditary angioedema (HAE) is a rare condition marked by swelling episodes in various body parts, including the extremities, upper airway, face, intestinal tract, and genitals. Long-term prophylaxis (LTP), prescribed to control recurring HAE attacks, is integral to its management. Previously, attenuated androgens (AAs) were the only oral LTP options. However, in 2020, berotralstat, an oral plasma kallikrein inhibitor, was approved in the United States. A 2018 survey of adults with HAE type I or type II showed that almost all the patients who used prophylactic HAE medication preferred oral treatment (98%) and felt that it fit their lifestyle better than injectable treatment (96%). Still, guidelines lack consensus on transitioning patients from AAs to alternative oral prophylactic therapy. Objective: This paper aims to share expert insights and patient feedback on transitioning from AAs to berotralstat, an alternative oral prophylactic therapy, from the perspective of clinicians with extensive experience in treating patients with HAE. Methods: A panel of five HAE specialists convened for a virtual half-day roundtable discussion in April 2023. Results: Discussions about transitioning from AAs to berotralstat were prompted by routine consultations, patient inquiries based on independent research, ineffective current treatment, or worsening AA-related adverse effects. For patients who switched from AAs, the physicians reported that the decision was influenced by the alternative therapy's ability to prevent HAE attacks, its safety, and the once-daily administration schedule. All expert panel members identified fewer AA-related adverse effects; better quality of life; and less severe, shorter, and less frequent HAE attacks as clinical or patient goals they hoped to achieve through the treatment switch. Conclusion: The emergence of new, highly specific LTP drugs for HAE calls for the development of comprehensive recommendations and guidelines for transitioning from AAs to alternative oral prophylactic therapy. The expert panel highlighted key factors to consider during the development of such guidelines.
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Affiliation(s)
- William R Lumry
- From the Allergy and Asthma Research Associates Research Center, Dallas, Texas
| | | | - Henry H Li
- Institute for Asthma and Allergy, Chevy Chase, Maryland
| | - Donald S Levy
- Division of Basic and Clinical Immunology, Department of Medicine, University of California at Irvine, Orange, California
| | | | | | | | - Raffi Tachdjian
- Division of Allergy & Clinical Immunology, David Geffen School of Medicine at UCLA, Los Angeles, California
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